**Send o riginal and**  **one copy of this form**  **and all other docum**  **entation to:** Health Education Assistance Loan (HEAL) Program Program Support Center (PSC) 12501 Ardennes Ave., Suite 100 Rockville, MD 20857 U.S. DEPARTMENT OF EDUCATION

Federal Student Aid FEDERAL HEALTH EDUCATION ASSISTANCE LOAN (HEAL) PROGRAM (42 U.S.C. 292

- 2920) and the Consolidation Appropriations Act, 2014 

### LENDER’S APPLICATION FOR INSURANCE CLAIM
PRA Burden Statement: A ccording to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection dis plays a valid OMB control number. T he valid OM B control number for this information collection is 1845
- 0127

. P ublic reporting bur den for this collection of information is estimated to average 30 minutes per response, including time for reviewing instruct ions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of in formation. T he obligation to respond to this collection is required to obtain or retain benefit (Title VII, Part A, Subpart I of the Public Health Service Act (42 U.S.C. 294m) and the Consolidated Appropriations Act, 2014). I f you have comment or concern s regarding the status of your individual submission of this form, please contact the HEAL Program, U.S. Department of Education 830 First Street NE, W ashington, DC 20202 directly. [Note: Please do not return the completed form to this address.] 

### General **Information** : The amount of Federal insurance payment receiv ed depends upon whether there is compliance with HEAL statue, regulations, and policies, including those concerned with the making, servicing, and collection of the loan (s) and the timely submission of documents

. (See Secti on 60.13 and 60.38 through 60.41. ) The following documents will assist you in completing this form: (1) HEA L Statute and Regulations; (2) Copy of borrow er’s application(s); (3) Or iginal Promissory Note (s); (4) Copy of disbursement check (s); (5) Copy of borrow er’s deferment request(s); (6) Evidence of student enrollment status and date of s eparation; (7) Repayment schedule (s); (8) Copy of borrow er’s forbearance request (s); (9) Litigation, bankruptcy, death, or disability documents; and (10) Payment and servicing history of borrower’s account. 

### Instructions for completing the form : **Item 1a**  **.** Holder (owner) of the HEAL loans. Provide six

- digit holder identification number, institution’s name, address, city, state, zip code, telephone number (including area code) , and fax number. **Item 1b**  **.** Servicer may be the same organization as the holder or a different organization. This is where the loans are being serviced. Provide six

- digit holder identification number, institution’s name, address, city, state, zip code, telephone number (including area code) , and fax number. **Item 1c**  **.** Claim T ype. Place an “X” in the appropr iate box that reflects the type of claim submitted. **Item 2**  **.** Provide borrow er’s nam e (if name has changed enter former name in p arentheses), social security number, last known address , including city, state , name of foreign country borrower reside (if applicable) and zip code. **Item 3**  **.** Provide 12

- digit HEAL Loan ID Number for each loan included in the claim, original loan and disbursed amount. For each loan ID number listed , the hol der m ust check appropriate columns as to documents included in the claim package under promissory note, application, repayment schedule, payment history, principal/interest calculation worksheet, and the number of months in deferment and forbearance. **It em** **4**
. Claim Information. Complete all information requested regarding dates, and signify yes or no answers by placing an “X” in the appropriate box. NOTE: Go to Item 5, 6, 7, 8, 9, 10, 11, or 12 according to claim type selected. Item 5
. Jud gm ent Claim Fill in the information requested or check yes or no. Item 6
. Bankruptcy Claim Fill in all information requested or check yes or no. Item 7
. Skip Claim Fill in all information requested or check yes or no. Item 8. Unable to Serve Claim Fill in all information requested or check yes or no. Item 9. Disab ility Claim Fill in all information requested or check yes or no. Item 10. Death Claim Fill in all information requested or check yes or no. Item 11. Low Loan Amount Claim Check yes or no. Item 12. Low Balance Cla im Check yes or no. Item 13. Enter the total amount of principal and interest fo r all loans claimed. Item s 14a
. , 14b

. , and 14c. Self

- explanatory The following must be completed before submitting the form: Assigned promissory note(s) to the United States Government Certified copy of the judgment and original assi gnm ent of the judgment to the United States Government A signed claim for m with supporting documentation